Provider Demographics
NPI:1033148291
Name:KWAK, SANDY (MD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:KWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4356
Mailing Address - Country:US
Mailing Address - Phone:630-859-6700
Mailing Address - Fax:
Practice Address - Street 1:1221 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1404
Practice Address - Country:US
Practice Address - Phone:630-859-8700
Practice Address - Fax:630-264-8428
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360901072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04515143OtherBCBS ID#
IL390361007Medicare PIN
IL0727500001Medicare NSC
IL390362006Medicare PIN
IL04515143OtherBCBS ID#